1. FINGERPRINT RECORD PREP SHEET
NAME: ___________________________________________ ALIAS: ____________________________
(Last, First, Middle)
ADDRESS:
SS# (XXX - XX - XXXX):
STATION: (highlight or circle one) SEATTLE CAMPUS AMERICAN LAKE MADIGAN
MET PARK VET CENTER BREMERTON MT VERNON
SERVICE LINE/DEPT:
JOB TITLE:
STATUS: IT/CWT EMPLOYEE WOC w/ Letter VOLUNTEER
CONTRACT WORKER MEDICAL STUDENT RESIDENT FELLOW
START DATE:
DATE OF BIRTH:
CITY / STATE / COUNTRY of BIRTH:
SEX: (highlight or circle one) MALE FEMALE
RACE (highlight or circle one): American-Indian Asian Black Caucasian Hispanic
HEIGHT (feet/inches):
WEIGHT (pounds):
EYE COLOR:
HAIR COLOR:
***FOR OFFICIAL USE ONLY***
DATE PRINTED: ________________________________ Assignment over 120 days:
PRINTED BY:____________________________________ YES / NO
(Revised October / 2014)